What are the commonly prescribed medications for patients with hypertension, cholesterol issues, or those requiring antibiotics, and what risk factors and alternative treatments should be considered in patients with existing medical conditions, impaired renal function, or impaired liver function?

Commonly Prescribed Medications: Risk Factors and Alternatives

Hypertension Medications

First-Line Agents

For most patients with hypertension, initial therapy should include an ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic, with the specific choice guided by patient demographics and comorbidities. 1

ACE Inhibitors (e.g., lisinopril, enalapril, benazepril)

Compelling Indications:

• Heart failure, post-MI, diabetes, chronic kidney disease, proteinuria 1
• Left ventricular hypertrophy, microalbuminuria 1

Risk Factors/Contraindications:

• Absolute contraindications: Pregnancy, angioedema history, bilateral renal artery stenosis 1
• Relative contraindications: Hyperkalemia (K+ >5.5 mEq/L), severe renal impairment 1
• Monitor serum potassium and creatinine 2-4 weeks after initiation, especially in patients with chronic kidney disease 2
• Common side effect: dry cough (5-10% of patients) 1

Alternatives:

• ARBs (angiotensin receptor blockers) provide similar benefits without cough 1
• Calcium channel blockers for patients who cannot tolerate ACE inhibitors/ARBs 1

Angiotensin Receptor Blockers (ARBs) (e.g., losartan, valsartan, olmesartan)

Compelling Indications:

• Same as ACE inhibitors: heart failure, post-MI, diabetes, chronic kidney disease 1
• Preferred alternative when ACE inhibitor causes cough 1

Risk Factors/Contraindications:

• Absolute contraindications: Pregnancy, bilateral renal artery stenosis 1
• Relative contraindications: Hyperkalemia, severe renal impairment 1
• Never combine with ACE inhibitors—dual RAS blockade increases hyperkalemia and acute kidney injury without cardiovascular benefit 2

Alternatives:

• Calcium channel blockers or thiazide diuretics 1

Calcium Channel Blockers (e.g., amlodipine, diltiazem, verapamil)

Compelling Indications:

• Angina pectoris, peripheral artery disease, isolated systolic hypertension in elderly, Black patients 1
• Previous stroke, asymptomatic atherosclerosis 1

Risk Factors/Contraindications:

• Dihydropyridines (amlodipine): May cause peripheral edema (10-15% of patients), tachyarrhythmias 1
• Non-dihydropyridines (diltiazem, verapamil): Contraindicated in heart failure with reduced ejection fraction, 2nd/3rd degree AV block 1
• Edema from amlodipine may be reduced by adding an ACE inhibitor or ARB 2

Alternatives:

• ACE inhibitors or ARBs for patients with heart failure 1
• Beta-blockers for patients with tachyarrhythmias 1

Thiazide Diuretics (e.g., hydrochlorothiazide, chlorthalidone)

Compelling Indications:

• Heart failure, isolated systolic hypertension in elderly, Black patients 1
• Chlorthalidone preferred over hydrochlorothiazide due to longer duration and superior cardiovascular outcomes 2

Risk Factors/Contraindications:

• Absolute contraindication: Gout 1
• Relative contraindications: Metabolic syndrome, glucose intolerance, pregnancy 1
• Monitor for hypokalemia, hyperuricemia, hyperglycemia 1
• May worsen lipid profile (increase total cholesterol and LDL) in short-term, though this often normalizes after 6-12 months 3, 4

Alternatives:

• Calcium channel blockers for patients with gout or metabolic syndrome 1
• Loop diuretics (furosemide) if eGFR <30 mL/min/1.73m² 1

Beta-Blockers (e.g., metoprolol, carvedilol, atenolol)

Compelling Indications:

• Post-MI, angina pectoris, heart failure with reduced ejection fraction, atrial fibrillation (rate control) 1

Risk Factors/Contraindications:

• Absolute contraindications: Asthma, 2nd/3rd degree AV block 1
• Relative contraindications: Peripheral artery disease, metabolic syndrome, glucose intolerance, COPD, athletes 1
• Less effective for stroke prevention compared to other classes 1
• May worsen lipid profile (increase triglycerides, decrease HDL) 4

Alternatives:

• Calcium channel blockers for angina without heart failure 1
• ACE inhibitors or ARBs for heart failure 1

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Cholesterol Medications

Statins (e.g., atorvastatin, rosuvastatin, simvastatin)

Indications:

• Primary prevention in patients with multiple cardiovascular risk factors 5
• Secondary prevention after MI, stroke, or established cardiovascular disease 5
• LDL-C reduction in hyperlipidemia, familial hypercholesterolemia 5

Risk Factors/Contraindications:

• Absolute contraindications: Acute liver failure, decompensated cirrhosis, pregnancy 5
• Risk factors for myopathy/rhabdomyolysis: Age ≥65 years, uncontrolled hypothyroidism, renal impairment, concomitant use of fibrates or certain drug interactions 5
• Drug interactions requiring dose limitation: Cyclosporine, gemfibrozil, certain antivirals (ritonavir-containing regimens), clarithromycin, itraconazole 5
• Monitor liver enzymes at baseline and if clinically indicated 5
• Monitor for muscle pain, weakness, or dark urine (signs of rhabdomyolysis) 5

Alternatives:

• Ezetimibe for patients intolerant to statins 6
• PCSK9 inhibitors for patients with familial hypercholesterolemia or statin intolerance 5

Special Considerations:

• Statins may modestly reduce blood pressure (2-5 mmHg systolic), particularly when combined with ACE inhibitors or calcium channel blockers 7
• Adjust dose in renal impairment and with interacting medications 5

Ezetimibe

Indications:

• Adjunct to statins for additional LDL-C lowering 6
• Alternative for statin-intolerant patients 6

Risk Factors/Contraindications:

• Avoid in acute liver failure or decompensated cirrhosis 6
• Dose adjustment needed in moderate-to-severe hepatic impairment (AUC increased 3-6 fold) 6
• Cyclosporine increases ezetimibe exposure 240% 6

Alternatives:

• Bile acid sequestrants (cholestyramine), though these reduce ezetimibe absorption by 55% 6

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Commonly Prescribed Antibiotics

Fluoroquinolones (e.g., ciprofloxacin, levofloxacin)

Risk Factors/Contraindications:

• Renal impairment: Dose reduction required based on creatinine clearance
• Hepatic impairment: Use with caution; monitor liver function
• Drug interactions: Avoid with antacids (aluminum/magnesium), which reduce absorption by 30% 6
• Cardiovascular risks: QT prolongation, avoid in patients with known QT prolongation or on QT-prolonging drugs
• Musculoskeletal risks: Tendon rupture (especially Achilles), particularly in elderly or corticosteroid users

Alternatives:

• Beta-lactams (amoxicillin, cephalosporins) for respiratory infections
• Macrolides (azithromycin) for atypical pathogens, though these also prolong QT

Macrolides (e.g., azithromycin, clarithromycin)

Risk Factors/Contraindications:

• Cardiovascular risks: QT prolongation, increased risk of sudden cardiac death in high-risk patients
• Drug interactions: Clarithromycin significantly increases statin levels (atorvastatin dose should not exceed 20 mg daily) 5
• Hepatic impairment: Use with caution; dose adjustment may be needed

Alternatives:

• Doxycycline for atypical respiratory infections
• Beta-lactams for typical bacterial infections

Beta-Lactams (e.g., amoxicillin, cephalexin, ceftriaxone)

Risk Factors/Contraindications:

• Penicillin allergy: Avoid penicillins; use cephalosporins with caution (5-10% cross-reactivity)
• Renal impairment: Dose adjustment required for most agents
• Generally safe in hepatic impairment

Alternatives:

• Fluoroquinolones or macrolides for penicillin-allergic patients
• Vancomycin for MRSA coverage

Sulfonamides (e.g., trimethoprim-sulfamethoxazole)

Risk Factors/Contraindications:

• Renal impairment: Dose reduction required; avoid if CrCl <15 mL/min
• Hyperkalemia risk: Particularly when combined with ACE inhibitors, ARBs, or spironolactone
• Sulfa allergy: Absolute contraindication
• Hepatic impairment: Use with caution

Alternatives:

• Nitrofurantoin for uncomplicated UTIs (avoid if CrCl <30 mL/min)
• Fluoroquinolones for complicated infections

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Key Clinical Pearls

For Hypertension:

• Black patients respond better to calcium channel blockers and thiazide diuretics than ACE inhibitors/ARBs 1
• Triple therapy should consist of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1, 2
• Spironolactone 25-50 mg is the preferred fourth agent for resistant hypertension 2
• Target BP <140/90 mmHg minimum, ideally <130/80 mmHg for high-risk patients 1

For Cholesterol:

• Statins are first-line for cardiovascular risk reduction 5
• Monitor for drug interactions, especially with cyclosporine, gemfibrozil, and certain antivirals 5
• Ezetimibe provides additional 15-20% LDL-C reduction when added to statins 6

For Antibiotics:

• Always check renal function before prescribing—most antibiotics require dose adjustment 6
• Review medication list for QT-prolonging drugs before prescribing fluoroquinolones or macrolides
• Clarithromycin requires statin dose limitation to prevent myopathy 5